The double-stapled ileal reservoir and ileoanal anastomosis

Fifteen consecutive patients (nine males and six females) who underwent construction of a double-stapled ileoanal reservoir (DS-IAR) were prospectively evaluated. Mean and maximal resting pressures preoperatively, before ileostomy closure, and at 12 months, were 53 and 84 mm Hg, 39 and 62 mm Hg, and 62 and 81 mm Hg. Mean and maximal squeeze pressures at those same time periods were 96 and 153 mm Hg, 111 and 173 mm Hg, and 95 and 168 mm Hg. There were no significant decreases in either resting or squeeze pressure between preoperative values and those obtained 12 months after surgery. However, the length of the high pressure zone decreased from 3–8 cm preoperatively to 2.3 cm at 12 months. This reflects the sacrifice of the cephalad 1.5 cm of the internal anal sphincter necessary to effect this anastomosis at a mean of 1.4 cm from the dentate line. However, this maneuver did not result in poor continence. Eleven patients whose ileostomies were closed for a mean of 9 months, ranging from 3 to 15 months, were evaluated regarding functional outcome. Only one patient had any incontinence and this patient had incomplete circularstapled tissue rings, which necessitated transanal suture repair of the anastomotic defect. Similarly, three of the four patients who sometimes or rarely use a pad at night had transanal-suture reinforcement. Ten of the 11 patients never wear a pad during the day. No pelvic or perianal sepsis occurred. Stratified squamous epithelium was found in 6 of the 13 distal stapler donuts that were examined. In addition, 10 patients underwent biopsy of the tissue immediately caudad to the circular staple line at the time of ileostomy closure; in five, only stratified squamous epithelium was noted. The DS-IAR is associated with excellent objective physiologic and subjective functional results.Read at the XIIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Graz, Austria, June 24 to 28, 1990.     

The ileal reservoir and ileoanal anastomosis procedure

A retrospective review was undertaken to determine factors important in predicting functional results following the ileal reservoir and ileoanal anastomosis procedure. One hundred seventy-nine patients underwent ileal reservoir and ileoanal anastomosis at the University of Toronto between December 1981 and January 1987. One hundred sixty-three patients had ulcerative colitis, 11 had familial adenomatous polyposis, and five had Crohn's disease. A J-reservoir was constructed in 72 patients and an S-reservoir in 107 patients. Functional results were assessed in 102 patients who had had their loop ileostomies closed for more than one year. The most significant technical complications were anal anastomotic leaks (10 percent), reservoir anastomotic leaks (3.9 percent), anal anastomotic stricture (7.8 percent), late fistula-inano (2.8 percent), small-bowel obstruction (19 percent), and loop ileostomy complications (23 percent). Overweight males and patients with operative blood loss greater than 1000 cc developed anal stricture more frequently (P<.005). Patients who had a stapled J-reservoir had a higher rate of reservoir leak. The average number of bowel movements reported by patients for 24 hours was 6.2±3.1. Only ten (9.8 percent) patients had to intubate their reservoir to empty it. Urgency was experienced by 24 patients and soilage at night by 23 (22.5 percent) and during the day by 18 (17.6 percent). Seven patients (6.8 percent) were incontinent during the night and only one during the day. Pouchitis was reported in 16 patients (15.7 percent). Patients with anal anastomotic stricture had more urgency and pouchitis, and had to intubate their reservoir more frequently (P<.05). No other factors analyzed affected technical or functional results. Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987. Colon and Rectal Surgical Fellowship sponsored by Rhone-Poulenc Pharma Inc., Montreal, Canada.     

Retained mucosa after double-stapled ileal reservoir and ileoanal anastomosis

A study was undertaken to assess the incidence of inflammation and dysplasia in retained mucosa after double-stapled ileoanal reservoir (IAR) for mucosal ulcerative colitis (MUC). Between September 1988 and February 1992, 56 patients with MUC underwent an IAR. Forty-five patients had a double-stapled IAR (DS-IAR), seven patients had a transanal pursestring stapled IAR (PS-IAR), and four patients had a PS-IAR with mucosectomy. Distal donuts obtained from the stapled IAR were submitted for pathologic review in 55 patients. Nine patients had only small bowel, connective tissue, and/or muscle noted on review. Mucosa was qualified as squamous epithelium (SE), transitional epithelium (TE), or columnar epithelium (CE). All samples were examined for evidence of inflammation and dysplasia. Four patients had SE only, one patient had TE, and 18 had CE. In addition, three patients had SE and CE, seven patients had SE and TE, two patients had CE and TE, and nine patients had all three types. The distance from the dentate line to the anastomosis ranged from 0 to 2.5 cm (mean, 1 cm). In 19 patients (35 percent), the distal donut revealed MUC. Of these 19 patients, six had persistent MUC (43 percent) at the time of subsequent biopsy. An additional four patients had MUC evident on follow-up biopsy but not on distal donuts; two of these four patients had no mucosa in their distal donuts. Only one of the patients with evidence of MUC on donuts and/or biopsy experienced any symptoms referable to active MUC (1.8 percent). None of the specimens examined had any evidence of dysplasia. In 31 patients, no MUC was present in the initial donuts or follow-up biopsies. Although the double-stapled technique appears safe, periodic monitoring is suggested.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Physiology of ileoanal anastomosis with ileal reservoir for ulcerative colitis and adenomatosis coli

A physiologic and metabolic assessment was carried out on eight patients six months after total proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatosis coli. All patients were continent and able to defecate spontaneously, stool frequency ranging from two to five per 24 hours. Anal sphincter resting pressures (35±14 mmHg) and squeeze pressures (88±24.2 mmHg) were similar to those of a healthy population, with the exception of one patient's complaint of nocturnal mucous leakage per anus. Biopsies of the ileal mucosa of the reservoirs showed a mild inflammation in seven patients; in one a subtotal villous atrophy (plus glandular pattern) was found. Anthropometric measurements, lymphocyte counts, hemoglobin, albumin, transferrin, iron, B₁₂, and folate were normal in all. In the majority of patients there was no evidence of bacterial overgrowth. Vitamin B₁₂ absorption was reduced slightly in only one patient. Lipid absorption (as judged by the¹⁴C-Triolein breath test) was abnormal in three patients. Fecal clearance of α₁ antitrypsin as protein losses index was abnormal in three patients. Bile acid malabsorption was the most important ileal dysfunction observed in the patients.     

Terminal ileal transposition procedure in ileoanal anastomosis following proctocolectomy

We introduced a terminal ileal transposition procedure (TITP) in ileal pouch-anal anastomosis, in which a 50 to 70 cm isolated ileal segment 20 to 40 cm from the ileocecal valve was interposed between the terminal ileum and the anus. Twelve patients underwent this procedure in two or three-staged operations. Mean stool frequency per 24 hours was 4.4±1.7, and stool consistency was formed and soft in all patients at the mean of 13 months after TITP. We observed neither surgical technique-related complications nor metabolic disorders, except for iron deficiency anemia, during and after the operations. The serum level of vitamin B12 significantly increased after the operation in eight patients (P<0.05). TITP has advantages such as preventing the terminal ileum from metabolic dysfunction due to pouchitis, avoiding sacrifice of the terminal ileum in the two-staged operation, and obviating the need for reconstruction of ileostomy in the three-staged operation. It may also promote intestinal absorption and reduce late metabolic complications. Accepted: 18 July 1997     

Endorectal mucosectomy, endorectal ileal pull-through and ileoanal anastomosis

Ileoanal anastomosis has evolved as a true alternative to proctocolectomy with permanent ileostomy over the past decade and has made a major impact on the operative treatment of patients with ulcerative colitis and familial polyposis. Experimental studies and clinical experience support the addition of a proximal ileal reservoir to the ileoanal anastomosis. Several types of reservoirs have been proposed of which the U-shaped reservoir has found the widest acceptance and the most frequent application. This reservoir constitutes an adequate replacement for the rectum by providing a low-pressure, compliant, peristaltically quiescent reservoir which still can be triggered to evacuate spontaneously at a reasonable threshold volume. Overall, the ileoanal anastomosis with proximal ileal reservoir fulfills the set clinical requirements: the underlying disease (polyposis, ulcerative colitis) is dealt with in a curative manner. An ileostomy is avoided. Anal continence is preserved. The operative procedure is safe and of comparable mortality and morbidity to the proctocolectomy with ileostomy. It is reasonable to expect that this procedure, i. e. ileoanal anastomosis with proximal ileal reservoir, will become the operation of choice for patients with ulcerative colitis and familial polyposis.     

An assessment of inflammation in the reservoir after restorative proctocolectomy with ileoanal ileal reservoir

The significance of inflammation of the mucosa of the ileal reservoir after restorative proctocolectomy is not known although in some cases it appears to be associated with symptoms when the condition has been referred to as pouchitis. This investigation has aimed to determined the prevalence of inflammation, to define pouchitis and to examine some factors which might be related to inflammation. Mucosal biopsies from the ileal reservoir were studied in 90 patients at up to 62 months after closure of the ileostomy. A histological grading system (0-6) was used to assess the severity of inflammation. Some degree of chronic and acute inflammation was found in 87% and 30% of cases respectively. The prevalence of a grade of 4 or more was 23% and 3.5%. There was a correlation between severity of chronic and acute inflammation. Severe histological acute inflammation (grade 4-6) was associated with sigmoidoscopic features of inflammation and with increased frequency of defaecation. Of 55 patients sigmoidoscoped by one clinician, 6 (11%) had pouchitis which was characterised by macroscopic inflammation of the reservoir, diarrhoea and a histological grade of 4 or more. The severity of chronic inflammation was not related to frequency of defaecation. Histological inflammation could not be correlated with the type of reservoir, residual volume after evacuation of a known volume of stool substitute introduced per anum into the reservoir or compliance of the reservoir. Acute inflammation was significantly more severe in patients with ulcerative colitis than in those with familial adenomatous polyposis.     

Straight ileoanal anastomosis with multiple ileal myotomies as an alternative to pelvic pouch

. An alternative technique of restorative proctocolectomy, by means of straight ileoanal anastomosis with multiple myotomies (SIAM) of the terminal ileum in 15 patients, nine with familial adenomatous polyposis (FAP) and six with ulcerative colitis (UC) is reported. Surgical technique: eight to ten longditudinal myotomies (3 – 4 cm long, on three different circumferential sites) were performed on the terminal ileum for a total length of 12 – 14 cm. Clinical results: at a mean follow up of 44 months (range 3 – 84 months) from the closure of the ileostomy, daytime continence was achieved in all the patients; stool frequency per 24 hours (±SD) was 4.1±1.8 for FAP patients and 5.8±1.7 for UC patients; nocturnal defecation was 1.0±0.5 and 1.2±0.8 for FAP and UC patients respectively; frequent nocturnal soiling was present in 2/5 of UC patients, and in 3/9 of FAP patients. SIAM failed in one UC patient that was converted to an ileoanal reservoir because of poor functional result. Signs of ileal mucosal inflammation were never observed at endoscopic examination. Histopathological assessment showed no evidence of acute terminal ileitis. Manometric findings: a significant postoperative reduction in anal resting pressure was observed after SIAM. Neither the absence of anal inhibitory reflex nor the presence of high pressure waves generated in the terminal ileum during air insufflation were related to the presence of soiling. The closure of the loop ileostomy was followed by an increased capacity and distensibility of the terminal ileum. Values of neorectal compliance were similar in FAP and UC patients although FAP patients were able to reach higher values of maximum tolerated volume and pressure. Conclusions: 1) SIAM can be an alternative to pelvic pouch in patients who have undergone restorative proctocolectomy when the construction of the pouch is not feasible. 2) The functional result observed after SIAM has been shown to be similar to that observed after pouch construction.     

Use of a nylon sleeve for safe reservoir downpulling during ileoanal anastomosis

The use of a nylon sleeve for an easier and safer reservoir downpulling during ileoanal anastomosis is described.     

A stapled S-shaped ileoanal reservoir

An S-shaped ileonal reservoir has the advantage of greater ease in obtaining adequate length for safe anastomosisvs. the J-pouch. The hand-sewn S-shaped pouch, however, takes considerably longer (70vs. 20 minutes) to construct than either a hand-sewn or stapled J-pouch. Because of potential necrosis of the central bridge of tissue created between two longitudinal stapled lines in an S-pouch, the same techniques of stapling a J-pouch cannot be used in an S-pouch. The authors have developed a safe, rapid, stapling technique for construction of an S-pouch in the dog and have used it with success in four patients.     

Secondary reconstruction of an ileal reservoir in patients with failed straight ileoanal pull-through: report of two cases

The ileoanal reservoir is a widely accepted option for the treatment of mucosal ulcerative colitis and familial adenomatous polyposis. Function of an ileoanal anastomosis without the reservoir may be unacceptable. The aim of this study was to assess the technical feasibility of conversion of a straight ileoanal anastomosis to an ileoanal reservoir anastomosis. Two patients underwent straight ileoanal anastomosis and then underwent subsequent conversion to an ileoanal reservoir anastomosis. A 16-year-old girl with mucosal ulcerative colitis and a 38-year-old woman with familial adenomatous polyposis presented with 20–25 bowel movements per day and severe diarrheal-related symptoms within 11 months of ileoanal anastomosis. In each case, the anastomosis was reversed and an ileal Jpouch was fashioned and anastomosed to the dentate line; there was no postoperative morbidity. The 38-year-old patient reported 4–5 bowel movements per day without the need for any medication at 1–8 months after ileostomy closure. The 16-year-old patient is waiting ileostomy closure. In conclusion, it is technically possible to convert a straight ileoanal anastomosis to an ileoanal reservoir anastomosis with expectations of improvement in function. Received: 30 January 2002 / Accepted: 25 September 2002     

A modified three-loop ileoanal reservoir

A modification of the Park's three-loop reservoir that allows spontaneous evacuation of the pouch by climinating the efferent limb is described.     

Endoscopic assessment of acute inflammation of the ileal reservoir after restorative ileo-anal anastomosis

Forty-seven patients, undergoing ileo-anal anastomosis for ulcerative colitis (42) or familial polyposis (5), were endoscopically examined after protective ileostomy or after restorative ileo-anal anastomosis. The neorectum and the ileum above were examined in all cases and multiple biopsies were taken. No symptoms of pouch inflammation were found in 41 subjects; 80.5% of these had non-macroscopic lesions and 19.5% had focal lesions such as congestion, petechiae, mucous hypersecretion (5), or single ulcers (3). None of these developed pouchitis. Pouchitis was observed in the other six subjects, who all underwent surgery for ulcerative colitis and developed 14 clinical episodes of pouchitis during the follow-up. In these cases the entire neorectum mucosa was always affected by the lesions which, in 50%, also extended to the ileum above. The most common endoscopic features (71.4%) were congestion, potechiae, oozing areas, mucous hypersecretion, and multiple superficial ulcers. In half the remaining cases (14.3%) the neorectum showed the features, described above, while the upper ileum was affected by deep round or irregular ulcers within normal mucosa; Crohn's disease was excluded in these cases. In the remaining 14.3%, pouchitis showed a pseudomembranous feature. In our experience, the endoscopic pattern of pouchitis is polymorphic. Although an ulcerative colitis-like feature prevails, pseudomembranous and Crohn's ileitis-like features may also be present.     

Water and electrolyte balance after ileoanal anastomosis

Water and electrolyte balance was studied in 30 patients with ileoanal anastomosis and J pouch, 10 patients with conventional ileostomy, and nine nonoperated patients with quiescent ulcerative colitis. Serum electrolyte concentrations, daily urinary volume, and daily losses of sodium, potassium, and chloride were measured in all patients. Daily fecal weight and daily losses of sodium and potassium were analyzed in patients with ileoanal anastomosis or conventional ileostomy. Serum chloride in patients with ileoanal anastomosis was significantly lower (P<0.05) than in those with conventional ileostomy or in nonoperated patients. Daily urinary loss of sodium in nonoperated patients was significantly higher than in patients with ileoanal anastomosis(P<0.01) or conventional ileostomy (P<0.05). Daily urinary loss of chloride in patients with ileoanal anastomosis was significantly lower (P<0.05) than in nonoperated patients. Daily fecal loss of potassium in patients with ileoanal anastomosis was significantly higher (P<0.05) than in those with conventional ileostomy. Daily urinary volume and fecal weight did not differ significantly in patients with ileoanal anastomosis or conventional ileostomy. The present study indicates that changes in water and sodium balance after ileoanal anastomosis are similar to those after conventional ileostomy but chloride balance is more altered after ileoanal anastomosis.     

Delayed ileal pouch-anal anastomosis

In patients with chronic ulcerative colitis (CUC), ileal pouch-anal anastomosis (IPAA) can be performed either at the time of colectomy or as a delayed procedure after total abdominal colectomy and ileostomy. There has been debate as to whether delayed IPAA results in superior functional results, since patients are frequently steroid-free and have little evidence of active disease. To assess this, we analyzed 95 patients who had undergone total abdominal colectomy, either with ileostomy and Hartmann's procedure or with ileorectostomy, 2–183 months prior to IPAA. Postoperative complications and functional results were compared with those of 776 CUC patients who underwent IPAA at the time of abdominal colectomy. Indications for prior colectomy included toxic megacolon (40 percent), failed medical therapy (36 percent), other reasons (e.g.,iatrogenic perforation, cancer) (6 percent), and reasons unclear (18 percent). Nineteen percent of delayed-IPAA patients were taking steroids at the time of pouch construction. Follow-ups were similar in the two groups. The incidence of septic and obstructive complications after delayed IPAA vs. IPAA at the time of colectomy were 10.5 percent vs.5.4 percent and 6.5 percent vs.14.5 percent, respectively. There were no significant differences in postoperative functional results between the two groups. Delayed IPAA confers no advantage over IPAA performed at the time of colectomy in terms of functional outcome. Delayed IPAA was associated with a significantly higher rate of septic complications but a lower incidence of postoperative obstruction.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Mesenteric lengthening in ileoanal pouch anastomosis for ulcerative colitis

PURPOSE: Lengthening of the mesentery is the technical key point of the ileoanal pouch procedure. Division of the superior mesenteric pedicle high in the mesentery is an original artifice that regularly provides sufficient descent of the pouch to reach the dentate line without any tension. A retrospective study compares two groups of patients with ulcerative colitis. METHODS: Group 1 consisted of 21 patients with superior mesenteric pedicle division (mean lengthening, 6.1 cm), and Group 2 consisted of 44 patients without superior mesenteric pedicle division. Mortality and postoperative and late morbidity were studied along with functional outcome. RESULTS: One patient died in Group 2 (postoperative pelvic sepsis); one patient died in Group 1 at six months from late liver transplant complications. Postoperative morbidity was insignificantly less important in Group 1 (P=0.02). Five patients in Group 2 had the pouch removed; none in Group 1 did. Pouchitis episodes developed in both groups, with no significant difference (P=0.5). Three patients in Group 1 developed anastomotic stenosisvs. 8 in Group 2 (P=0.5). Functional results at one-month, one-year, and two-year follow-ups are not significantly different, except that nighttime stool frequency increased in Group 2. CONCLUSIONS: On the whole, morbidity and functional outcome appear similar. This suggests that high superior mesenteric pedicle division has no adverse effect and can be proposed routinely as an effective lengthening technique.Presented at the meeting of the Association Française de Chirurgie, Paris, France, October 6 to 8, 1997.     

Long-term functional analysis of the ileoanal reservoir

Since November 1980, 180 patients underwent abdominal colectomy, rectal mucosectomy, ileoanal reservoir construction, and ileoanal anastomosis at the authors' institutions. One hundred twenty-nine patients had restoration of intestinal continuity before the end of 1986. One hundred fourteen of these patients (88 percent) were available for follow-up at a mean length of time of 5.0 years from ileostomy closure (range, 16 to 88 months). The mean number of pouch evacuations was 5.4±2.5 during the day (range, 1 to 12) and 1.5±1.0 at night (range, 0 to 6). Ninety-one percent of patients reported perfect or almost perfect daytime continence, and 74 percent found this true at night. Sixty-three percent of patients believed their pouch function continued to improve over many years. Ninety-five percent of patients questioned would choose an ileoanal reservoir again instead of a permanent ileostomy. This long-term assessment of the function of the ileoanal reservoir confirms that it is a viable, although not perfect, option in the management of ulcerative colitis and familial adenomatous polyposis. Poster presentation at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.